office of the municipal manager supplier … ggm... · office of the municipal manager supplier ......

Vision: A Municipality where environmental sustainability, tourism and agriculture thrive for Economic growth.

GREATER GIYANI MUNICIPALITY

Tel: 015 811 5500 P/Bag X 9559 Fax: 015 812 2068 Giyani 0826

OFFICE OF THE MUNICIPAL MANAGER

SUPPLIER APPLICATION FORM

Supplier Details

Company / Supplier Name: _____________________________________________________

_____________________________________________________

Trading Name if different from the above:________________________________________________

________________________________________________

NB: # Applicable to companies and Close Corporations, as with the Registrar of Companies / CC

## Insert Personal Income Tax Number for Sole Proprietor or Personal Income Tax Number for all parties

in terms of Partnerships

Company / Close Corporation Registration Number # 2 2 2 2 2 2 2 2 2 2 2 2 2

VAT registration number (if applicable) 4 8 3 0 1 9 6 2 4 4

Income tax reference number##

Web Address:

E-mail Address:

Telephone Number: 0 1 5 8 1 1 5 5 0 20

Fax Number: (compulsory)

Toll Free Number:

Number of employees: Full-time

Part-time

Business Postal Address: (Compulsory) Business Physical Address: (Compulsory)

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Code Code

2

Contact Person (Print names in full)

Surname and Names 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Position in company:

Cell Phone Number:

Fax Number:

E-mail address

Preferred method of correspondence (x)

Fax E-mail Telephone

Company / Supplier Classification (please √ the relevant box or boxes)

Services Manufacturer Repairer Distributor Sales Importer Exporter

(Please (x) the relevant)

Tax Clearance Certificate attached Yes No

Expiry date

Supplier Grouping Detail: Legal Status (Please √ the relevant box)

Public Company (Ltd)

Private Company (Pty) Ltd

Close Corporation (cc)

Other (specify)

Joint Venture

Consortium

Sole Proprietor

Foreign Company

Partnership

Trust

Section 21 Company

Government / Organ of state / Parastatal

(see terminology page )

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Terminology:

Please read notes below very carefully

o Owned:

Having all the customary element of ownership, including the right of decision-making and

sharing all the risks and profit commensurate with the ownership interests as demonstrated by

an examination rather than the form of ownership arrangements.

o Broad Base Black Economic Empowerment:

As a minimum requirement, all valid B-BBEE Status Level Verification Certificates should

have the following information detailed on the face of the certificate:

ecard that was used (for example EME, QSE or Generic);

-BBEE Status Level of Contribution obtained by the measured entity..

o Women:

A female person, who is a South African citizen

o Disability:

In respect of a person, a permanent impairment of physical, intellectual, or sensory function,

which results in restricted or lack of ability to perform an activity in the manner, or within the

considered normal for a human being.

o Fronting:

Companies with no Broad Base Black Economic Empowerment (BBBEE) status illegally

claiming to be headed by HDI and claim false BBBEE credentials in order to win tenders /

contracts

o Joint Venture

An association of persons for the purpose of combining their expertise, property, capital,

efforts, skill and knowledge for execution of contract

o Relative

In this document means: yours first degree relative, that is, wife, husband, son, daughter, father,

mother, brother, sister

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Ownership details only

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MBD 4 Service provider must with immediate effect notify Supply Chain Management Office of any changes to this declaration.

DECLARATION OF INTEREST

1. No bid will be accepted from persons in the service of the state. 2. Any person, having a kinship with persons in the service of the state, including a blood

relationship, may make an offer or offers in terms of this invitation to bid. In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons connected with or related to persons in service of the state, it is required that the bidder or their authorised representative declare their position in relation to the evaluating/adjudicating authority and/or take an oath declaring his/her interest.

3 In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

3.1 Full Name: ……………………………………………………………………………………………………… 3.2 Identity Number: ..…….……………………………………………………………………………………………… 3.3 Company Registration Number: ……………………………………………………………………………… 3.4 Tax Reference Number: ……………………………….………………………………………………………… 3.5 VAT Registration Number: ….………………………………………………...…………………………………

3.6 Are you presently in the service of the state YES / NO

3.6.1 If so, furnish particulars. ……………………………………………………………… ……………………………………………………………… 3.7 Have you been in the service of the state for the past twelve months? YES/NO 3.7.1 If so, furnish particulars. ……………………………………………………………… ………………………………………………………………

MSCM Regulations: “in the service of the state” means to be – (a) a member of –

(i) any municipal council; (ii) any provincial legislature; or (iii) the national Assembly or the national Council of provinces;

(b) a member of the board of directors of any municipal entity; (c) an official of any municipality or municipal entity; (d) an employee of any national or provincial department, national or provincial public entity or constitutional institution within the

meaning of the Public Finance Management Act, 1999 (Act No.1 of 1999); (e) a member of the accounting authority of any national or provincial public entity; or (f) an employee of Parliament or a provincial legislature.

Greater Giyani Municipality

Database Registration Form

6

3.8 Do you, have any relationship (family, friend, other) with persons in the service of the state and who may be involved with the evaluation and or adjudication of this bid? YES/NO 3.8.1 If so, furnish particulars. ……………………………………………………………… 3.9 Are you, aware of any relationship (family, friend, other) between a bidder and any persons in the service of the state who may be involved with the evaluation and or adjudication of this bid? YES/NO 3.9.1 If so, furnish particulars

…………………………………………………………….

3.10 Are any of the company’s directors, managers, principle YES/NO shareholders or stakeholders in service of the state? 3.10.1 If so, furnish particulars. ……………………………………………………………… 3.11 Are any spouse, child or parent of the company’s directors, YES/NO

managers, principle shareholders or stakeholders in service of the state?

3.11.1 If so, furnish particulars. ………………………………………………………………

CERTIFICATION

I, THE UNDERSIGNED (NAME) ……………………………………………………………..………………………………………………………

CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS CORRECT.

I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

……………………………………………………………………….. ………………….……………….…………………………….……………….. Signature Date

…………………………………………………………………………. ………………………………………………………….…………………………. Position Name of Bidder



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MBD 8

DECLARATION OF BIDDER’S PAST SUPPLY CHAIN MANAGEMENT PRACTICES

1 This Municipal Bidding Document must form part of all bids invited.

2 It serves as a declaration to be used by municipalities and municipal entities in

ensuring that when goods and services are being procured, all reasonable steps are

taken to combat the abuse of the supply chain management system.

3 The bid of any bidder may be rejected if that bidder, or any of its directors have:

a. abused the municipality’s / municipal entity’s supply chain management

system or committed any improper conduct in relation to such system;

b. been convicted for fraud or corruption during the past five years;

c. willfully neglected, reneged on or failed to comply with any government,

municipal or other public sector contract during the past five years; or

d. been listed in the Register for Tender Defaulters in terms of section 29 of

the Prevention and Combating of Corrupt Activities Act (No 12 of 2004).

4 In order to give effect to the above, the following questionnaire must be completed and

submitted with the bid.

Item Question Yes No

4.1 Is the bidder or any of its directors listed on the National Treasury’s

database as a company or person prohibited from doing business with

the public sector?

(Companies or persons who are listed on this database were informed in

writing of this restriction by the National Treasury after the audi alteram

partem rule was applied).

Yes

No

4.1.1 If so, furnish particulars:

4.2 Is the bidder or any of its directors listed on the Register for Tender

Defaulters in terms of section 29 of the Prevention and Combating of Corrupt

Activities Act (No 12 of 2004)?

(To access this Register enter the National Treasury’s website,

www.treasury.gov.za, click on the icon “Register for Tender Defaulters”

or submit your written request for a hard copy of the Register to

facsimile number (012) 3265445).

Yes

No


4.3 Was the bidder or any of its directors convicted by a court of law (including a

court of law outside the Republic of South Africa) for fraud or corruption

during the past five years?

Yes

No


http://www.treasury.gov.za/



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Item Question Yes No

4.4 Does the bidder or any of its directors owe any municipal rates and taxes or

municipal charges to the municipality / municipal entity, or to any other

municipality / municipal entity, that is in arrears for more than three months?

Yes

No


4.5 Was any contract between the bidder and the municipality / municipal entity

or any other organ of state terminated during the past five years on account of

failure to perform on or comply with the contract?

Yes

No


CERTIFICATION

I, THE UNDERSIGNED (FULL NAME) …………..……………………………..……

CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION

FORM TRUE AND CORRECT.

I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT,

ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BE

FALSE.

………………………………………... …………………………..

Signature Date

………………………………………. …………………………..

Position Name of Bidder



9

PLEASE INDICATE BY (√) THE FIELD OF COMPETENCE YOUR FIRM WILL BE REGISTERING IN:

Description Category

Description Category

PROFESSIONAL SERVICES A – R 332.00 Personal and Suppliers C – R127.00

Corporate Governance & Related Consulting Office Cleaning Materials

Tax and Financial Management Consulting Printing & Stationery

Risk Assessment & Management Services Auto Repairs and Maintenance

Internal Auditing Building Materials / Hardware Materials

Forensic Auditing Flight Bookings, Car Rental, Accommodation (Travel Agents)

Compliance Assurance Conference Facilities

Performance Management Security Services

Skills Development Supply of Office Furniture

Job Evaluation Suppliers Repair of Office Furniture

Training & Development Institution (Accredited) Protective Clothes and Uniforms

Insurance Service Cleaning Services

Health Care Consulting Supply of Air Conditioning Equipment & Maintenance

Debt Collection Special Events and Function Management Services

Legal Consultants Advertising

Civil Engineers Video & Photography

Quantity surveyors Transportation Services

Town Planners Graphic Design

Architecture Printing of Booklets & Publications (design, layout & Printing)

Other (please specify) Plumbing Materials

Stage, Sound & Multimedia Service

Electrical Materials Supplier

CONSTRUCTION B – R 198.00 Purification Services

Building Maintenance and Construction Bolts & Nuts

Roads Maintenance and Construction Courier Services

Fencing Other (please specify)

Landscaping / earthworks

Paving

Painting

Other (please specify)

CATERING (Only) D – R 99.00

Categories of Services Providers

CATERGORY SERVICE PROVIDER REGISTRATION FEE

A. Professional Services R 332.00

B. Construction R 198.00

C. Personal and Suppliers R 127.00

D. Catering R 99.00



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Interest of shareholders in other consulting firms

Name of person Name of other

firm Type of business

Nature of

interest % of ownership

PAYMENT ARRANGEMENT

F1. Credit terms:

No credit terms 30 days 60 days Other (Specify):

F2. Interest rates on overdue account:

F3. Details of discounts:

___________________________________________________________________________________

F4. Details of guarantees on goods and services:

Past experience

Most recent projects undertaken (started or finished within the last 3 years)

PROJECT

DURATION

PROJECT

DESCRIPTION CLIENT AMOUNT

CONTACT

PERSON

PHONE

NUMBER



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Annual turnover of own work (tick in the applicable block)

Income Level

Below current VAT threshold (R 300 000)

Between VAT threshold and R1 million

Between R2 million and R5 million

Between R5 million and R15 million

CREDIT ORDER INSTRUCTION FORM

ATTENTION

I/We hereby request and authorise Greater Giyani Municipality to pay any amounts which accrue to me/us

to the credit of my / our bank account with the mentioned bank.

_____________________________ _________________ _________

Initials and surname Authorised signature Date

Name of Organisation

Name of Bank

Branch Code

Account Number

Type of account Cheque Saving Bond Transmission Other

Date Stamp of Bank

Bank account particulars Certified as Correct

Bank Statement can also be attached /

copy of cancelled cheque

Processed by: Authorised by:

Signature: Signature:

Date: Date:



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Attachments to this form

a) A company profile, detailing the services/goods you provide (max 5 pages)

b) Copy of Company certificate.

c) Valid Tax Clarence Certificate( Expiry date must be six (6) months and above)

d) Income Tax Certificate

e) VAT registration certificate (for VAT vendors only)

f) Certified copy of Identity Document for all members/partners/shareholders

g) Certified copy of BBBEE certificate

h) Original Tax Clearance

i) Municipal Statement or letter from Tribal Authority

Note: Service Providers must from time to time visit Greater Giyani Municipality website to check for requests for

quotations on various goods and services. www.greatergiyani.gov.za

PARTICULARS OF OWNER / PERSON ACTING AS REPRESENTATIVE

I/we the undersigned acknowledge that:

o The information furnished is true and correct

o Any conflict of interest has been declared in the MBD 4

Full names of representative: ___________________________________________________

Capacity / Designation: ___________________________________________________

Contact Number: _________________________________

Signature:________________________________ Date: ________________________

FOR OFFICE ONLY

DATE RECEIVED DATE CAPTURE

APPLICATION APPROVED

Yes No

COMPLETED BY:

Signature: Date:

BANKING DETAILS

Bank Name : ABSA {G G M STAMP}

Account Name : Greater Giyani Municipality

Branch Code : 630-369

Account Number : 4077078193

http://www.greatergiyani.gov.za/

office of the municipal manager supplier … ggm... · office of the municipal manager supplier ......

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